1. Have you previously used
radiation dosimeters at any location?
If Yes, record name, address and contact
person where dosimetry was previously used...............................>
|
|
Company/Institution
Name: |
|
Department & Supervisor: |
|
Street
Address/P.O. Box: |
|
City
|
State
Zip:
|
Dates
of Employment: |
|
2. Do you currently use
radiation dosimeters at any of
the following locations?
Other location:
If Yes, record
name, address and contact
person where radiation dosimetry
is currently being
used.....................................>
|
Yes
or No
|
Company/Institution
Name: |
|
Department & Supervisor: |
|
Street
Address/P.O. Box: |
|
City
|
State
Zip:
|
Dates
of Employment: |
|
***Please note that
you are required to notify Radiation Safety
if you are now, or later become a radiation
worker at another company/institution. This
information is needed to accurately track
radiation exposure. |
3. If you answered
'YES' to No. 2, will dosimetry
be continued after beginning
work at UMB?
Yes
No
N/A
|
4. Do you work with any of the following radioactive materials or radiation producing machines?
(choose "None" if
applicable, do not leave blank)>:
(Hold down the ctrl key to select more than one item)
|
5. Ring Profile:
Dominant hand:
Right
Left
N/A
Ring size:
Small
Medium
Large
|
6. The UMB dosimetry policy specifies
that radiation workers must be issued
dosimeters if they are expected to
receive 100 millirem in a year. The
Radiation Safety Office will review
your expected exposure and determine
if you will be required to wear a
dosimeter based on policy guidelines.
Radiation workers may voluntarily
wear dosimeters for their own information,
but will be required to abide by
all dosimetry policies should they
choose to do so.
Do you wish to receive a dosimeter even
if Radiation Safety may not require you
to do so?
Yes or
No
|
This is to certify that to the best
of my knowledge, the information
contained herein is complete and
accurate and to authorize the release
of my radiation exposure and bioassay
history and other pertinent information
to the University of Maryland, Baltimore.
Authorized
User/Dosimetry
Coordinator:
Authorization/Series Number:
Date Submitted:
|